Axis I psychopathology in individuals with traumatic brain injury

OBJECTIVES: To assess the incidence, comorbidity, and patterns of resolution of DSM-IV mood, anxiety, and substance use disorders in individuals with traumatic brain injury (TBI). DESIGN: The Structured Clinical Interview for DSM-IV Diagnoses (SCID) was utilized. Diagnoses were determined for three onset points relative to TBI onset: pre-TBI, post-TBI, and current diagnosis. Contrasts of prevalence rates with community-based samples, as well as chi-square analysis and analysis of variance were used. Demographics considered in analyses included gender, marital status, severity of injury, and years since TBI onset. SETTING: Urban, suburban, and rural New York state. PARTICIPANTS: 100 adults with TBI who were between the ages of 18 and 65 years and who were, on average, 8 years post onset at time of interview. MAIN OUTCOME MEASURES: SCID Axis I mood diagnoses of major depression, dysthymia, and bipolar disorder; anxiety diagnoses of panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and phobia; and substance use disorders. RESULTS: Prior to TBI, a significant percentage of individuals presented with substance use disorders. After TBI, the most frequent Axis I diagnoses were major depression and select anxiety disorders (ie, PTSD, OCD, and panic disorder). Comorbidity was high, with 44% of individuals presenting with two or more Axis I diagnoses post TBI. Individuals without a pre-TBI Axis I disorder were more likely to develop post-TBI major depression and substance use disorders. Rates of resolution were similar for individuals regardless of previous psychiatric histories. Major depression and substance use disorders were more likely than were anxiety disorders to remit. CONCLUSION: TBI is a risk factor for subsequent psychiatric disabilities. The need for proactive psychiatric assessment and timely interventions in individuals post TBI is indicated.     

Verbal fluency in individuals with mild traumatic brain injury.

Tests of verbal fluency that require either retrieval by semantic category or retrieval by initial letter were presented to 19 participants with mild traumatic brain injury (MTBI) and 24 control (NC) participants. Performance on these tasks was analyzed for total number of words produced, the presence of semantic clusters in the order of words produced, the presence of phonemic clusters in the order of words produced, and number of errors (i.e., perseverations, words out of category). Individuals with MTBI produced fewer words and made more errors than NCs, but their production contained an equal proportion of semantic and phonemic clusters. These data are discussed in relation to a previous study in patients with Parkinson's disease (PD). PD participants did not make more errors than age-matched NCs despite reduced production. Implications for memory and executive function deficits following MTBI are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neuropsychological testing and functional outcome for individuals with traumatic brain injury

The relationship between performance on neuropsychological measures and the vocational and independent living functioning of individuals with traumatic brain injury was examined. The Wechsler Adult Intelligence Scale-Revised (WAIS-R) IQ and Stroop Color and Word Test scores differentiated individuals who required no assistance with activities of daily living from those requiring some level of assistance. Only the Stroop Color and Word Test scores differentiated individuals who were competitively employed or engaged in degree-oriented education from those who were unemployed or in sheltered or supported employment. Wechsler Memory Scale-Revised (WMS-R) scores did not differentiate these groups.     

Exploring sandplay therapy: Application to individuals with traumatic brain injury.

Adolescents with traumatic brain injury (TBI) often experience social, emotional, and behavioral challenges requiring intervention. Although sandplay techniques have been used with targeted populations, there are no published accounts of sandplay applications with children or adolescents with TBI. This article explores the merits of sandplay approaches for clients with TBI with respect to key features of TBI, including language, communication, psychosocial, and executive function impairments. Two case examples of adolescents with TBI treated with sandplay therapy are presented, followed by discussion and recommendations for further study in the application of this technique with individuals experiencing emotional or behavioral difficulties associated with TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A stress process model of caregiving for individuals with traumatic brain injury.

Objective: To test a stress process model of caregiving for persons with traumatic brain injury. Design: A correlational study using path analysis. Participants: One hundred eight caregivers affiliated with community- or Web-based support groups. Main Outcome Measures: The Modified Caregiver Appraisal Scale, the World Health Organization Quality of Life-Brief Version, the Interpersonal Support Evaluation List, and the COPE. Results: The normed fit index, comparative fit index, and parsimony ratio indicated a good fit for the model, suggesting that coping, social support, and caregiving appraisal contribute to quality of life. A more parsimonious model was respecified and achieved a better fit with fewer paths and variables. Conclusions: Empirical support was found for the proposed caregiving stress process model, which appears to provide useful information for future research and clinical interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The influence of memory beliefs in individuals with traumatic brain injury.

Objective: To explore metamemory (memory beliefs) and affective functioning in individuals with traumatic brain injury (TBI). Participants: Twenty-six individuals with mild TBI (MTBI), 16 individuals with severe TBI (STBI), and 42 uninjured adults. Outcome Measures: Metamemory in Adulthood questionnaire, Postconcussion Syndrome Checklist, Perceived Stress Scale, Beck Depression Inventory (2nd ed.), Beck Anxiety Inventory. Results: The control group endorsed higher memory self-efficacy, fewer depressive symptoms, fewer memory strategies, and fewer postconcussion symptoms than the MTBI or STBI group. The MTBI group placed high importance on success in memory tasks. Memory self-efficacy and memory-strategies use mediated the relation between TBI and depression. Conclusion: Individuals with brain injury hold negative beliefs about their memory functioning, and such beliefs contribute to depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Religion and spirituality in rehabilitation outcomes among individuals with traumatic brain injury.

Objective: The long-term consequences of traumatic brain injury affect millions of Americans, many of whom report using religion and spirituality to cope. Little research, however, has investigated how various elements of the religious and spiritual belief systems affect rehabilitation outcomes. The present study sought to assess the use of specifically defined elements of religion and spirituality as psychosocial resources in a sample of traumatically brain injured adults. Participants: The sample included 88 adults with brain injury from 1 to 20 years post injury and their knowledgeable significant others (SOs). The majority of the participants with brain injury were male (76%), African American (75%) and Christian (76%). Measures: Participants subjectively reported on their religious/spiritual beliefs and psychosocial resources as well as their current physical and psychological status. Significant others reported objective rehabilitation outcomes. Analyses: Hierarchical multiple regression analyses were used to determine the proportion of variance in outcomes accounted for by demographic, injury related, psychosocial and religious/spiritual variables. Results: The results indicate that religious well-being (a sense of connection to a higher power) was a unique predictor for life satisfaction, distress and functional ability whereas public religious practice and existential well-being were not. Conclusions: The findings of this project indicate that specific facets of religious and spiritual belief systems do play direct and unique roles in predicting rehabilitation outcomes whereas religious activity does not. Notably, a self-reported individual connection to a higher power was an extremely robust predictor of both subjective and objective outcome. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Life activities among individuals with spinal cord injury living in the community: Perceived choice and perceived barriers.

Objective: To apply the World Health Organization model of functioning to a study of perceived choice over life activities and barriers to engaging in life activities among persons with spinal cord injury. Participants and Setting: This large community-dwelling sample included 255 participants from 2 urban sites and 1 rural site. Measure: Items from the Participation of People With Mobility Limitations Survey were used. Results: Approximately half of the participants reported little or no perceived choice with employment, and the majority reported low levels of satisfaction with choice with employment. Access to employment was limited by physical barriers (48%) and transportation (46%). Physical impairment, pain, and fatigue were also barriers. Conclusions: Improvements of workplace and transportation accessibility, increased vocational supports, and interventions to decrease pain and fatigue are needed to ensure participation for persons with spinal cord injury. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interventions for students with traumatic brain injury: managing behavioral disturbances

The present article provides information about the behavioral sequelae that are commonly seen in children and adolescents following a traumatic brain injury (TBI) and ways that educators can begin to address these problems. Because, for the most part, behavioral interventions have not been empirically validated for use with TBI populations, this article focuses on the unique needs of these students and the factors that should be considered in designing intervention strategies. Emphasis is placed on the cognitive sequelae of TBI that can cause further behavioral problems and interfere with interventions (e.g., impaired attention, executive function, reasoning and problem solving, and learning and memory).     

Social problem solving and community integration in postacute rehabilitation outpatients with traumatic brain injury.

Objective: To enhance understanding of the role that social problem solving (SPS) plays in community integration following traumatic brain injury (TBI). Study Design: Regression analysis. Participants: Forty-five adults with TBI participating in higher level outpatient cognitive rehabilitation and 15 uninjured adults. Main Outcome Measures: Measures of community integration, problem-solving ability, and SPS self-appraisal and performance. Results: Individuals with TBI demonstrated poorer problem-solving as measured by both neuropsychological and SPS methods; however, the largest effect' size was observed for SPS self-appraisal. Only SPS self-appraisal predicted a significant proportion of the variance in community integration. Conclusions: It is important to assess brain-injured persons' confidence in their ability to cope with problems. A focus on objective test scores alone may lead to underdetection of disabling problem-solving deficits. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trajectories of life satisfaction in the first 5 years following traumatic brain injury.

Objectives: The trajectories of life satisfaction for 609 individuals who sustained a traumatic brain injury (TBI) were studied. Hierarchical linear modeling analysis examined individual level growth trends over the first 5 years following TBI using gender, functional independence, age, and time to estimate life satisfaction trajectories. Measures: Participants completed the Functional Independence Measure and the Life Satisfaction Inventory at years 1, 2, 4, and 5 after sustaining TBI. Results: Participants who reported higher functional independence at year 1 also had higher life satisfaction at year 1. Participants with lower functional independence across the 5-year period had life satisfaction trajectories that decreased at significantly greater rates than the individuals with more functional independence. The life satisfaction trajectory declined for the sample, but participants reporting lower cognitive and motor functional independence had significantly greater declines in life satisfaction trajectories. Age and gender were not significant factors in predicting life satisfaction trajectories following TBI. Implications: Individuals with greater cognitive and motor impairments following TBI are likely to experience significant declines in life satisfaction within 5 years of living with TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting community integration following traumatic brain injury with health and cognitive status measures.

Objective: To examine measurement properties of the Community Integration Questionnaire (CIQ) and the Short-Form Health Survey (SF-36) and assets the contributions of cognitive functioning and health to community integration. Design: Rating scale analyses and regression analysis data on basic cognitive functioning and health collected from 289 individuals with traumatic brain injury. Results: Person reliabilities indicated substantial measurement error. Ceiling effects weakened the model (adjusted R2 = .143) specifying the contributions of age, gender, cognitive functioning, and health to community integration. Conclusions: Poor measurement properties and definitional problems associated with community integration weakened the results. The extent to which potential familial and environmental characteristics contributing to role fulfillment change across time requires further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conversational assessment following traumatic brain injury: a comparison across two control groups

Although changes in discourse are frequently referred to in the traumatic brain injury (TBI) literature, they are difficult to objectify and measure. It is not always easy, therefore, for clinicians to differentiate between discourse behaviours which may have been present premorbidly, and those which are uniquely associated with TBI. The major aim of this study was to systematically examine and describe the nature of conversational impairment following severe TBI, with particular reference to the premorbid sociolinguistic characteristics of the TBI population. A second aim of the study was to examine the relationship between discourse impairment following TBI and severity of injury. Twenty-six TBI participants were compared with 26 non-brain-injured orthopaedic patients, and 26 university students, using Damico's Clinical Discourse Analysis (CDA). As predicted, global measures derived from the CDA did not differentiate the groups. The TBI group was, however, found to differ significantly from both control groups on a modified measure (CDA-M) which removes discourse errors that occurred with similar frequency across the three groups. Performance on this measure correlated significantly with severity of injury. Further, it was found that there were quantitative and qualitative differences between two seventy subgroups in the TBI group with respect to their CDA-M profiles. While nearly all members of the TBI group made errors associated with information transfer, only the more fundamental 'rules' of conversational interaction. The results are discussed in relation to the psychosocial implications of the findings, together with issues in sampling and measuring conversational discourse in the TBI population.     

Management of the patient with minor traumatic brain injury

Staff in the accident and emergency department and critical care unit are often confronted with patients who have sustained life-threatening injuries. In such situations the symptoms of a minor traumatic brain injury (MTBI) may be missed. It is important that, when the physical symptoms begin to subside, nurses are aware of the symptoms of MTBI and respond accordingly. A post-concussion syndrome may develop 2 weeks to 2 months after a MTBI. This syndrome can affect the patient's ability to perform the usual activities of living. This article defines MTBI, describes the symptoms encountered in patients with MTBI, and outlines the pathophysiology, clinical findings, treatment and nursing interventions.     

Extremity fractures in the patient with a traumatic brain injury

Extremity fractures are common in patients with traumatic brain injuries (TBIs). These injuries are often inadequately treated and occasionally are completely missed due to the unique problems inherent to the TBI patient. However, appropriate evaluation of the TBI patient allows prompt diagnosis and optimal treatment of extremity fractures. The increased survival rate of these patients has resulted in a greater emphasis on minimizing dysfunction and disability, especially that due to concomitant orthopaedic trauma. Advances in anesthestic technique permit earlier operative fixation of extremity fractures. Most injuries, particularly those in the lower extremity, require operative stabilization to allow early mobilization and rehabilitation. Upper extremity fractures are often associated with peripheral nerve injuries. Heterotopic ossification is common, especially about the elbow and hip. Contrary to prevalent belief, fracture healing is not necessarily accelerated in the TBI patient; hypertrophic callus, myositis ossificans, and heterotopic ossification occur frequently and are often misperceived as accelerated healing.